• No results found

To study the “Demographic and etiological profile of severe acute malnutrition in children aged 6 months to 59 months in an urban tertiary care centre”.

N/A
N/A
Protected

Academic year: 2022

Share "To study the “Demographic and etiological profile of severe acute malnutrition in children aged 6 months to 59 months in an urban tertiary care centre”."

Copied!
95
0
0

Loading.... (view fulltext now)

Full text

(1)

INTRODUCTION

Severe acute malnutrition is a preventable and treatable cause of childhood morbidity and mortality.

Childhood undernutrition is an important public health & development challenge in India.

India is a home to greatest population of severely malnourished children in the world.

Malnutrition is often found to start in the womb and end in the tomb.

Children with Severe acute malnutrition have 9 times higher risk of dying than well nourished children.

Besides increasing the risk of death and disease, undernutrition also needs to growth retardation and impaired psychosocial and cognitive development.

With appropriate nutritional and clinical management, many of the deaths due to severe wasting can be prevented.

In 2015, globally among children of <5 year of age,15% had underweight, 40% were stunted & 8% of them were found to have wasting, This represents 101 million underweight children, 165 million stunted children, and 52 million wasted children.(1)

(2)

Asia carries 69% of the global burden of underweight children, 58% of the global burden of stunted children, and 70% of the global burden of wasted children because of the combination of large population size and high prevalence.

According to NFHS IV data, under five mortality rate in INDIA is 27 per 1000 live birth, wherein 45% of under 5 mortality is accounted by malnutrition alone and it remains a key public health challenge in India.(2)

Fetal growth restriction along with suboptimal breastfeeding in the first few months of life contribute to 19% of all deaths in children <5 year.

When the combined effects of stunting, wasting and deficiencies of vitamin A and zinc are also considered, they jointly contribute to 45% of global child deaths (3.1 million deaths/year), and many more are disabled or stunted for life.

According to UNICEF, every year, one million children under five, die due to malnutrition related causes in India. As per the WHO classification of the severity of malnutrition, the statistics are alarming and far above the emergency threshold for malnutrition.

According to the Global Hunger Index(GHI) for 2019, India ranked 102 among 118 developing nations, 15.2% of Indians are undernourished and 38.7% of under-five children are stunted.(3)

(3)

NFHS IV survey shows the prevalence of wasting is 19.7%,severe wasting is 7.9%,stunting is 27% and underweight is 23.8%.(2)

Maximum prevalence of wasting was seen in Jharkhand (29%) and minimum in Kerala.(2)

Only one-fifth of children were stunted in Kerala as compared to nearly half (48.3%) in Bihar. It was noted that, occurrence of stunting was inversely proportional to the educational status of the parents and the wealth quintiles of the families.(2)

For children <5 yr, the global prevalence is estimated to be 33% for vitamin A deficiency, 29% for iodine deficiency, 17% for zinc deficiency, and 18% for iron-deficiency anemia.(2)

Malnutrition in India is not just related to calorie intake, but India’s dependence on a carbohydrate based diet, which is deficient in protein and fat.

The first 1000 days of life, from conception to 24 months of age, is the period where the risk of undernutrition (underweight, stunting, wasting, and micronutrient deficiencies) is greatest.

The early damage to growth and development can have adverse consequences in later life on health, intellectual ability, school achievement, work productivity, and earnings.

(4)

Therefore interventions to focus on this critical window of opportunity has been advised.

Nutritional rehabilitation centres are being set up in the health facilities for inpatient management of severely malnourished children, with counseling of mothers for proper feeding and once they are on the road to recovery, they are sent back home with regular follow up.

Death among SAM are preventable, provided timely and appropriate actions are taken.

DEFINITION

Severe acute malnutrition is defined as severe wasting and/or bilateral edema.

Severe wasting is extreme thinness diagnosed by a weight-for-length (or height) below −3 SD of the WHO Child Growth Standards.

In children ages 6-59 months, a mid-upper arm circumference <115 mm also denotes extreme thinness: a color-banded tape is a convenient way of screening children in need of treatment.

Bilateral edema is diagnosed by grasping both feet, placing a thumb on top of each, and pressing gently but firmly for 10 seconds. A pit (dent) remaining under each thumb indicates bilateral edema.

(5)

This definition of severe acute malnutrition distinguishes wasted/

edematous children from those who are stunted.

Stunted children are not a priority for acute clinical care as their deficits in height and weight cannot be corrected in the short term.

The previous name protein-energy malnutrition is avoided, as it oversimplifies the complex multideficiency etiology.

Other terms are

marasmus (severe wasting),

kwashiorkor (characterized by edema), and marasmic- kwashiorkor (severe wasting + edema).

CLASSIFICATION OF UNDERNUTRITION

CLASSIFICATION INDEX GRADING

Gomez (underweight)

90-75% of median weight- for-age

Grade 1 (mild)

75-60% Grade 2 (moderate)

<60% Grade 3 (severe)

(6)

Waterlow (wasting)

90-80% of median weight- for-height

Mild

<70% Severe

Waterlow (stunting)

95-90% of median height- for-age

Mild

90-85% Moderate

<85% Severe

WHO (wasting)

<−2 to >−3 SD weight-for- height

Moderate

<−3 Severe

WHO (stunting)

<−2 to >−3 SD height-for- age

Moderate

<−3 Severe

WHO (wasting) (for age group 6-59 mo)

115-125 mm mid-upper arm circumference

Moderate

<115 mm Severe

(7)

ASSESSMENT OF NUTRITIONAL STATUS

Nutritional status is often assessed in terms of anthropometry.

International standards of normal child growth under optimum conditions from birth to 5 yr have been established by the World Health Organization (WHO).

In children less than 2years of age, length measured using an infantometer. Weight is measured using electronic weighing scale. Height is measured using stadiometer in children more than 2years of age. Height is measured using the steps as follows.

Children should stand straight with the shoes and socks removed.

They should look straight.

They should stand in a relaxed manner with arms hanging by the sides.

They should stand with both feet and knees close together.

The head should be kept in Frankfurt plane: The line joining the lower margin of the orbit and the upper margin of the external auditory canal should be parallel to the ground.

Mid upper arm circumference is measured using a non-stretchable measuring tape, midway between the acromion and the olecranon process with the arm hanging by the side of the body.

To compile the standards, longitudinal data from birth to 24 months of

(8)

healthy, breastfed, term infants were combined, with cross-sectional measurements of children ages 18-71 months.

The standards allow normalization of anthropometric measures in terms of z scores (standard deviation scores).

A z-score is the child’s height (weight) minus the median height (weight) for the age and sex of the child divided by the relevant standard deviation.

Having been derived from a large multi country study, which reflects diverse ethnic backgrounds and cultural settings, the standards are applicable to all children everywhere.

Height-for-age(or length-for-age for children <2 yr) is a measure of linear growth, and a deficit represents the cumulative impact of adverse events, usually in the first 1,000 days from conception, that result in stunting, or chronic malnutrition.

A low weight-for-height, or wasting, usually indicates acute malnutrition.

Weight-for-ageis the most commonly used index of nutritional status, although a low value has limited clinical significance as it does not differentiate between wasting and stunting.

Mid-upper armcircumferenceis another tool used for screening wasted children.

(9)

MICRONUTRIENT DEFICIENCIES

Micronutrient deficienciesare another dimension of undernutrition.

Vitamin A, iodine, iron, and zinc deficiency have public health significance.

Vitamin A deficiencyis caused by a low intake of retinol or beta- carotene. The prevalence of clinical deficiency is assessed from symptoms and signs of xerophthalmia.

Vitamin A is the leading cause of preventable blindness in children. It is also associated with a higher morbidity and mortality among young children.

Iodine deficiencyis the main cause of preventable mental impairment.

An enlarged thyroid is a sign of iodine deficiency.

Severe deficiency of iodine during pregnancy may cause fetal loss. In surviving children it can cause permanent damage to the central nervous system,i.e.,cretinism.

Iodine supplementation before conception or during the first trimester of pregnancy can prevent fetal loss & cretinism. Postnatal iodine deficiency is

(10)

associated with impaired mental function and growth retardation.

Iron-deficiency anaemiais common in childhood. It is either due to low iron intake, poor absorption, illness or parasite infestation.

Haemoglobin cut-off to define anaemia is110 g/L for children 6-59 months.

Zinc deficiencyincreases the risk of morbidity and mortality from diarrhoea& pneumonia. It also has an adverse effect on linear growth.

CAUSES OF UNDERNUTRITION

Under nutrition is a condition where there is inadequate consumption or poor absorption or excessive loss of nutrients.

Many poor nutritional outcomes begin in uterowhich manifests as low birthweight (BW<2,500 g). LBW is mainly due to preterm delivery and fetal growth restriction.

Prematurity is relatively more common in richer countries and fetal growth restriction is relatively more common in poorer countries.

LBW accounted for 15% of births in low and middle income countries.

Rates of LBW are highest (26%) in southern Asia, which are twice those of sub-Saharan Africa. India accounts for approximately 40% of the world’s low- weight births.

(11)

Primary causes:

• Lack of adequate intake of food.

• Poverty: Inability to spend money on food in order to fulfill nutritional requirements.

• Ignorance: Lack of awareness of the nutritional qualities of food.

• Food fads: Reservations for eating specific foods.

• Traditional habits: Continuation of breast milk without introduction of complementary feeding at appropriate age, use of overdiluted food formulas and restriction of food intake during periods of certain illness like diarrhea

• Social and cultural factors: Males are given more food than females.

• Congenital defects like cleft palate and cleft lip, which interfere with food intake

• Intrauterine growth retardation (IUGR) and maternal malnutrition predispose child to undernutrition later in life.

Secondary Causes: Undernutrition occurs despite adequate intake of food

• Chronic illness and infections : Increased metabolic needs and lack of appetite.

(12)

• Malabsorption/impaired utilization

• Excessive loss: Gastroenteritis

• Drugs: INH predisposes to pyridoxine deficiency, phenytoin predisposes to folic acid deficiency.

CONSEQUENCE OF UNDERNUTRITION

The most important consequence of undernutrition is premature death.

Even with mild undernutrition, there is increased risk of child death from infectious diseases and as the severity of undernutrition increases, the risk of mortality increases exponentially.

Childhood infections are more severe and longer lasting in undernourished children, as undernutrition impairs immune function and other host defenses, and more likely to be fatal, when compared with the same illnesses in well-nourished children.

The childhood diseases assessed in NFHS-4 were episodes of diarrhea, acute respiratory infections (ARI) and anemia.

The incidence of diarrhea remained the same (9%) between NFHS-3 and NFHS-4. Maximum incidence of diarrhea has been observed in Uttar Pradesh (15%) while the least was seen in Kerala (3.4%).

There was an increase in the intake of Oral Rehydration Salt (ORS),

(13)

Prevalence of ARI almost halved from the level of 5.6% in NFHS-3 to 2.75 in NFHS-4.

Integrated Action Plan for Pneumonia and diarrhea has been formulated for four states with highest child mortality (Uttar Pradesh, Madhya Pradesh, Bihar and Rajasthan) to address the two biggest killers of children, namely Pneumonia and Diarrhea.

Integrated Management of Neonatal and childhood Illness (IMNCI) for early diagnosis and case management of common ailments of children with special emphasis on pneumonia, diarrhea and malnutrition is being promoted for care of children at community as well as

Also, infections can adversely affect nutritional status, it can lead to a cycle of repeated infections and ever-worsening malnutrition.

For the survivors, physical and cognitive damage due to undernutrition can impact their future health and economic well-being.

For girls, the cycle of undernutrition is passed on to the next generation, when undernourished women give birth to LBW babies.

Fetal growth restriction and early childhood undernutrition may also have consequences for chronic illness in adulthood.

“Fetal programming,” a process by which fetal undernutrition leads to permanent changes, in the structure and metabolism of organs and systems, can

(14)

manifest as disease in later life.

LBW is associated with greater risk of hypertension, stroke, and type 2 diabetes. The risk is exacerbated by low weight gain during the first 2 year of life

Stunting before the age of 3 yr, is associated with, poorer motor and cognitive development and altered behavior in later years.

Iodine and iron deficiencies also lead to loss of cognitive potential.

Children living in areas of chronic iodine deficiency have an average reduction in IQ of 12-13.5 points compared with children in iodine-sufficient areas.

Iron deficiency has a detrimental effect on the motor development of children <4 years and on cognition of school-age children. The estimated deficit is 1.73 IQ points for each 10 g/L decrease in hemoglobin concentration.

Undernutrition can also have substantial economic consequences for survivors and their families. The consequences can be quantified under 5 categories

1.Increased costs of healthcare, either neonatal care for LBW babies or treatment of illness for infants and young children

2. Productivity losses (and hence reduced earnings) associated with smaller stature and muscle mass

(15)

3. Productivity losses from reduced cognitive ability and poorer school performance

4.Increased costs of chronic diseases associated with fetal and early child malnutrition

5.Consequences of maternal undernutrition on future generations

PATHOPHYSIOLOGY

Children who have had a diet which is insufficient in energy and nutrients relative to their needs end up in severe acute malnutrition.

Depending upon the duration of inadequacy, quantity and diversity of food taken, individual variation in requirements, presence of antinutrients and number & severity of coexisting infections and their duration, the magnitude of the deficits will differ.

The heterogeneity in the extent and nature of the deficits and imbalances among each child explains the differences in the clinical presentation and degree of metabolic disturbance, reflecting the diverse pathways which lead to severe acute malnutrition.

The cause of edematous malnutrition is more likely due to exposure to noxae, which inturn leads to generation of oxidative stress and/or to have greater deficits in free radical-scavenging antioxidants like glutathione, vitamins A, C, and E, and essential fatty acids or cofactors like zinc, copper, selenium.

(16)

GOPALAN’S THEORY OF ADAPTATION:

Gopalan’s theory says that marasmus develops due to good adaptation to poor diet while kwashiorkor is the result of adaptation failure.

In marasmus, decreased calorie intake leads to decreased insulin levels and increased cortisol levels. Increased cortisol level leads to tissue catabolism, which causes muscle wasting. In this process, glucose and amino acids are released into the circulation. The glucose is utilized by the brain and the amino acids are used for synthesis of albumin and Beta – lipoprotein. Thus, the albumin level is maintained in the blood and hence no oedema occurs in marasmus. The Beta lipoprotein helps in mobilizing the fat from the liver;

hence the fat is not accumulated in the liver.

In kwashiorkor, there is increase in insulin level which prevents tissue catabolism. Hence, the amino acids are not available for albumin synthesis and Beta lipoproteins are not formed. Hence, oedema and fatty liver develop.

When a child’s intake is not sufficient to meet daily needs, in an orderly progression, physiologic and metabolic changes take place to conserve energy and prolong life. This process is called reductive adaptation.

To provide energy fat stores are mobilized.

Next protein in muscles, skin, and the gastrointestinal tract is mobilized.

Energy is conserved by reducing physical activity and growth, reducing

(17)

basal metabolism and the functional reserve of organs and by reducing inflammatory and immune responses.

All these changes have important consequences:

The liver produces glucose less readily, leading the child more prone to hypoglycemia. It alsocauses decreased production albumin, transferrin, and other transport proteins. The ability to excrete toxins is reducedand is less able to cope with excess dietary protein.

Child is more vulnerable to hypothermia as the heat production is less.

Fluid easily accumulates in the circulation, causing increased risk of fluid overload, as the kidneys are less able to excrete excess fluid and sodium.

The heart is smaller and weaker and cardiac output is reduced, and fluid overload readily leads to death due to cardiac failure.

Sodium builds up inside cells, due to leaky cell membranes and reduced activity of the sodium/potassium pump, leading to excess body sodium, fluid retention, and edema.

Potassium leaks out of cells and is excreted in urine, contributing to electrolyte imbalance, fluid retention, edema, and anorexia.

Loss of muscle protein is accompanied by loss of potassium, magnesium, zinc, and copper.

(18)

Motility is reduced, and bacteria may colonize the stomach and small intestine, damaging the mucosa and deconjugating bile salts. The gut produces less gastric acid and enzymes. Digestion and absorption are impaired.

Cell replication and repair are reduced, increasing the risk of bacterial translocation through the gut mucosa.

Immune function is impaired, especially cell-mediated immunity. The usual responses to infection may be absent, even in severe illness, increasing the risk of undiagnosed infection.

Red cell mass is reduced, releasing iron which requires glucose and amino acids to be converted to ferritin, increasing the risk of hypoglycemia and amino acid imbalances. If conversion to ferritin is incomplete, unbound iron promotes pathogen growth and formation of free radicals.

Micronutrient deficiencies limit the body’s ability to deactivate free radicals, which cause cell damage. Edema and hair/skin changes are external signs of cell damage.

CLINICAL FEATURES

Initially there is failure to gain weight followed by weight loss resulting in wasting.Severe wasting is most visible on the thighs, buttocks, and upper arms, and over the ribs and scapulae, where loss of fat and skeletal muscle is

(19)

greatest.

As subcutaneous tissues are broken down to provide energy, the skin loses turgor and becomes loose.

The face may retain a relatively normal appearance, but eventually becomes wasted and wizened.

The eyes may be sunken from loss of retroorbital fat, and lachrymal and salivary glands may atrophy leading to lack of tears and a dry mouth.

Weakened abdominal muscles and gas from bacterial overgrowth of the upper gut may lead to a distended abdomen.

Severely wasted children are often fretful and irritable.

In edematous malnutrition, the edema is most likely to appear first in the feet and then in the lower legs. It can quickly develop into generalized edema affecting also the hands, arms, and face.

Skin changes commonly occur over the swollen limbs and include dark, crackled peeling patches (flaky paint dermatosis) with pale skin underneath that is easily infected.

The hair is sparse and easily pulled out and may lose its curl. In dark- haired children, the hair may turn pale or reddish.

The liver is often enlarged with fat.

(20)

Children with edema are miserable and apathetic, and often refuse to eat.

Grading of kwashiorkor:

Grade I: Pedal oedema Grade II: I + Facial oedema

Grade III: II + Paraspinal and chest oedema Grade IV: III + Ascites

Grading of Marasmus:

Grade Area of loss of fat

I Axilla and Groin

II Grade I + thigh / buttocks

III Grade II + Chest / abdomen

IV Grade III + buccal pad of fat

Face Moon face (kwashiorkor), simian facies (marasmus)

Eye

Dry eyes, pale conjunctiva, Bitot spots (vitamin A), periorbital edema

Mouth

Angular stomatitis, cheilitis, glossitis, spongy bleeding gums (vitamin C), parotid enlargement

Teeth Enamel mottling, delayed eruption

(21)

Hair

Dull, sparse, brittle hair, hypopigmentation, flag sign (alternating bands of light and normal color), broomstick eyelashes, alopecia.

Skin

Loose and wrinkled (marasmus), shiny and edematous (kwashiorkor), dry, follicular hyperkeratosis, patchy hyper- and hypopigmentation (crazy paving or flaky paint dermatos,erosions, poor wound healing.

Nails

Koilonychia, thin and soft nail plates, fissures, or ridges

Musculature

Muscle wasting, particularly buttocks and thighs;

Chvostek or Trousseau sign (hypocalcemia)

Skeletal

Deformities, usually as a result of calcium, vitamin D, or vitamin C deficiencies

Abdomen

Distended: hepatomegaly with fatty liver; ascites may be present

Cardiovascular

Bradycardia, hypotension, reduced cardiac output, small vessel vasculopathy

Neurologic

Global developmental delay, loss of knee and ankle reflexes, impaired memory

Hematologic Pallor, petechiae, bleeding diathesis

(22)

Behavior Lethargic, apathetic, irritable on handling

TREATMENT

The treatment procedures are similar for marasmus and kwashiorkor.

1.Treat/prevent hypoglycemia

2. Treat/prevent hypothermia

3. Treat/prevent dehydration

4. Correct electrolyte imbalance

5. Treat/prevent infection

6. Correct micronutrient deficiencies

7. Start cautious feeding

8.Achieve catch-up growth

9.Provide sensory stimulation and emotional support

(23)

These steps are accomplished in two phases, an initial stabilization phase where the acute medical conditions are managed and a longer rehabilitation phase.

COMMUNITY-BASED THERAPEUTIC CARE

The CTC concept combines facility or inpatient management of severe acute malnutrition with complications, and community based management of severe acute malnutrition without complications or mild or moderate malnutrition.

These facility based and community based components of management should be closely linked so that children who are too ill to be treated at the community level or who are not responding to treatment can be referred to the facility level and those receiving facility based treatment who have regained their appetites can be transferred for continued care in the community.

Bihar has introduced a Community- based Management of Acute Malnutrition (CMAM) program.

PREVENTION OF MALNUTRITION

Improvement of nutrition status of children is an essential component of health care.

(24)

Interventions to address child undernutrition can be divided into those that address immediate causes (nutrition-specific interventions) and those that address underlying causes (nutrition-sensitive interventions)

Interventions focusing on both fetal and postnatal periods can reduce the adverse effects of undernutrition on mortality, morbidity, and cognitive development.

Prevention of low maternal BMI and anemia, and, prevention of low maternal stature can prevent fetal LBW in the longer term.

In the postnatal period, highest priority should be given to promote and support exclusive breastfeeding.

Baby Friendly Hospital Initiative has a marked benefit on rates of exclusive breastfeeding in hospital, postnatal counseling from community workers or volunteers is needed to facilitate continuation of exclusive breastfeeding at home for 6 mo.

Exclusively breastfed children of HIV-infected mothers in low-income countries have lower mortality than non-breastfed children, as the latter are at increased risk of death from diarrhea and pneumonia.

For complementary feeding, nutrient-rich, energy- dense mixtures of foods, and responsive feeding, are often emphasized. Messages taken to community should be few in number, feasible, and culturally appropriate

(25)

In places where adequate complementary feeding is difficult to achieve and subclinical deficiencies are common, supplementation with high-dose vitamin A every 6 month in children <5 yr of age can reduce child mortality by 5-15% and zinc supplementation can reduce 1-4 yr mortality by 18%, incidence of diarrhea by 13%, and pneumonia by 19%.

Monitoring of child growth, accompanied by good counseling and growth promotion activities, provides an early alert to a nutrition or health problem.

The impact of growth monitoring and promotion will be related to coverage, intensity of contact, health worker performance and communications skills, adequacy of resources, and the motivation and ability of families to follow agreed actions.

PREVENTION AT NATIONAL LEVEL

NUTRITION SUPPLEMENTATION

This can be done by improvement of food and feeding; by fortification of staple food; iodination of common salt and food supplementation.

NUTRITIONAL SURVEILLANCE

Surveillance defines the character and magnitude of nutritional problems and selects appropriate strategies to counter these problems.

NUTRITIONAL PLANNING.

(26)

Nutritional planning involves a political commitment by the government, formulation of a nutrition policy and planning to improve production and supplies of food and ensure its distribution.

Dietary diversification still remains the most appropriate way forward, though supplementation and fortification should also be considered potential solutions to fill nutritional gaps.

PREVENTION AT COMMUNITY LEVEL

A.HEALTH AND NUTRITIONAL EDUCATION.

Lack of awareness of the nutritional quality of common foods, irrational beliefs about certain foods and cultural taboos about feeding contribute to the development of malnutrition.

People should be informed of the nutritional quality of various locally available and culturally accepted low cost foods.

B. PROMOTION OF EDUCATION AND LITERACY IN THE COMMUNITY, especially nonformal education and functional literacy among village women.

c. GROWTH MONITORING.

The growth should be monitored periodically on growth cards. Velocity of growth is more meaningful than the actual weight of a child.

(27)

d. INTEGRATED HEALTH PACKAGE.

Primary health care package should be made available to all sectors of population including preventive immunization, oral hydration, periodic deworming and early diagnosis and treatment of common illnesses.

e. VIGOROUS PROMOTION OF FAMILY PLANNING PROGRAMS to limit family size.

PREVENTION AT FAMILY LEVEL

EXCLUSIVE BREASTFEEDING OF INFANTS FOR FIRST 6MONTHSof life should be vigorously promoted and encouraged.

Breastmilk is the ideal for growth and development of infants.

Ideally, breastfeeding should be initiated within one hour of birth followed by frequent, on-demand feeding (WHO 2004).

Despite knowing the advantages of breastmilk in improving child survival, only 54.9% of children are exclusively breastfed in India.

Breastfeeding was initiated within one hour in 41.6% of the children, which has almost doubled since the last round of NFHS-3 (23.4%). This increase corresponded with simultaneous increase in institutional deliveries by almost double (from 38.7% to 78.9%).

Breastfeeding within one hour of birth was the highest in the state of Odisha (68.6%), followed by kerala (64.3%) and least in UP (25.2%).

(28)

Exclusive breastfeeding of the infants less than 6 months of age was observed in slightly more than half (54.9%) of the infants at the national level.

Minimum practice was observed in the UP (41.6%) and the maximum in Chhattisgarh (77.2%).

Early initiation of breastfeeding, exclusive breastfeeding and initiation of complementary feeding after six months and appropriate Infant and Young Child Feeding (IYCF) practices are being promoted by the Ministry of health and family welfare collaboration with the ministry of Woman and Child Development.

A recent initiative launched in August 2016, Mothers Absolute Affection (MAA) Program, is directed towards promotion of breast feeding among mothers and includes awareness generation, community level interventions and health facility strengthening and monitoring.

b. COMPLEMENTARY FOODS should be introduced in the diet of infants at the age of 6 months.

c. VACCINATION.

The immunization coverage in 12-23 months old children has increased from 43.5% in NFHS-3 to62% in NFHS-4.

The coverage of almost all vaccines has increased by about 20% since the previous survey.

(29)

Majority (90.2%) of the children received most of their vaccines from public health care facilities.

The overall coverage is still low despite existence of Universal Immunization Program (UIP) for three decades.

Mission Indradhanush has been launched in a phased manner for immunization against seven vaccine-preventable diseases in the year 2015.

Newer vaccines have been introduced into the national immunization schedule, viz, pentavalent vaccine, rotavirus vaccine and injectable poliovirus vaccine..

d. IATROGENIC RESTRICTION of feeding in fevers and diarrhoea should be discouraged.

e. ADEQUATE TIME should be allowed between two pregnancies so as to ensure proper infant feeding and attention to the child before the next conception.

INTEGRATED CHILD DEVELOPMENT SERVICES (ICDS) PROGRAMME

The ICDS programme is an intersectoral program which seeks to directly reach out to children, below six years, especially from vulnerable groups and remote areas.

The Scheme provides an integrated approach for converging basic

(30)

services through community-based workers and helpers.

The services are provided at a center called the 'Anganwadi'.

A package of six services is provided under the ICDS Scheme:

a. SUPPLEMENTARY NUTRITION.

b. IMMUNIZATION. Immunization of pregnant women and infants is done against the six vaccine preventable diseases.

c. NON FORMAL PRESCHOOL EDUCATION.

d. HEALTH CHECK-UP. This includes health care of children less than six years of age, antenatal care of expectant mothers and postnatal care of nursing mothers. These services are provided by the ANM and Medical Officers under the RCH programme. The various health services include regular health check- ups, immunization, management of malnutrition, treatment of diarrhea, deworming and distribution of simple medicines.

e. REFERRAL SERVICES. During health check-ups and growth monitoring, sick or malnourished children are referred to the Primary Health Centre or its subcenter.

f. NUTRITION AND HEALTH EDUCATION.

NATIONAL PROGRAMME OF MID-DAY MEALS IN SCHOOLS

With a view to enhancing enrolment, retention and attendance and

(31)

simultaneously improving nutritional levels among children, the National Programme of Nutritional Support to Primary Education (rechristened National Programme of Mid-day Meals in Schools in 2007) was launched as a centrally sponsored scheme on 15th August 1995, initially in 2408 blocks in the country.

The Mid day Meal Scheme (MDM) is an initiative that focuses on promotion of food security, nutrition and access to education for children.

The National Programme of Mid-day Meals in Schools covers approximately 9.70 crore children studying at the primary stage of education in 9.50 lakh Government (including local bodies), Government aided schools and the centers run under Education Guarantee Scheme and Alternative and Innovative Education Scheme.

The program provides a mid-day meal of 450 kcal and 12 g of protein to children at the primary stage. For children at the upper primary stage, the nutritional value is fixed at 700 kcal and 20 g of protein. Adequate quantities of micro- nutrients like iron, folic acid and vitamin A are also recommended.

The program has helped in protecting children from classroom hunger, increasing school enrolment and attendance, improved socialization among children belonging to all castes, addressing malnutrition and social empowerment through provision of employment to women.

NATIONAL NUTRITION ANAEMIA PROPHYLAXIS PROGRAMME

This program was launched in 1970 to prevent nutritional anemia in

(32)

mothers and children.

Children in the age group of 1-5 year are given one tablet containing 20 mg elementary iron (60 mg of ferrous sulfate) and 0.1 mg of folic acid daily for a period of 100 days.

The prevalence of anemia decreased by 10% during the time period between NFHS-3 (69.4%) and NFHS-4 (58.4%).

Prevalence remained more than 50% in almost all states except Odisha (44.6%), Chhattisgarh (41.6%) and Kerala (35.6%). The maximum prevalence of anemia was seen in Jharkhand (69.9%) while the least was observed in Kerala (35.6%).

Weekly Iron Folic Acid supplementation program (WIF) is a promising initiative aimed at supplementation with Iron Folic Acid at the level of the schools and anganwadis.

Bi-weekly Iron Folic Acid (IFA) supplementation by ASHA for children aged 6 to 59 months and weekly Iron Folic Acid Supplementation (WIFS) for children 5 to 10 years (known as WIFS junior) have been launched.

Thirteen States have initiated bi-weekly IFA supplementation for children 6 to 59 months and ten States have initiated WIFS junior for children 5 to 10 years.

Sustained efforts are required along with intensive monitoring

(33)

NUTRITION REHABILITATION CENTERS

Nutrition Rehabilitation Centers (NRCs) have been set-up at facility level to provide medical and nutritional care to Severe Acute Malnourished (SAM) children under 5 years of age who have medical complications.

Children are admitted as per the defined admission criteria and provided with medical and nutritional therapeutic care.

Once discharged from the NRC, the child continues to be in the Nutrition Rehabilitation program till she/he attains the defined discharge criteria from the program.

In addition to curative care, special focus is given on timely, adequate and appropriate feeding for children; and on improving the skills of mothers and caregivers on complete age appropriate caring and feeding practices.

In addition, efforts are made to build the capacity of mothers/caregivers through counseling and support to identify the nutrition and health problems in their child.

SERVICES AND CARE AT NRC

(34)

• 24 hour care and monitoring of the child

• Treatment of medical complications

• Therapeutic feeding

• Providing sensory stimulation and emotional care

• Social assessment of the family to identify and address contributing factors

• Counseling on appropriate feeding, care and hygiene

• Demonstration and practice- by -doing on the preparation of energy dense child foods using locally available, culturally acceptable and affordable food items

• Follow up of children discharged from the facility

LOCATION AND SIZE OF NRC

NRC is a special unit, located in a health facility and dedicated to the initial management and nutrition rehabilitation of children with severe acute malnutrition.

At a district hospital/medical college hospital, the NRC should have 10- 20 beds depending on the size of that ward.

The unit should be a distinct area within the health facility and should

(35)

The NRC should have the following-

• Patient area to house the beds; in NRC adult beds are kept so that the mother can be with the child .

• Play and counseling area with toys; audiovisual equipment like

TV, DVD player and IEC material

• Nursing station

• Kitchen and food storage area attached to ward, or partitioned in the ward, with enough space for cooking, feeding and demonstration

• Attached toilet and bathroom facility for mothers and children along with two separate hand washing areas.

The approximate covered area of the NRC should be about 150 square feet per bed, plus 30% for ancillary area.

A 10 bedded NRC should have a covered area of about 1950 square feet;

this will include the patient area, play and counseling area, nursing station, kitchen, storage space, two bathrooms and two toilets.

NRC should have a cheerful, stimulating environment; it should be child friendly. Walls can be brightly painted and decorated.

Ward should have sufficient space for all mothers /caregivers staying with the children to sit together and be given cooking and feeding demonstration.

(36)

STAFF REQUIREMENT

• Medical officer/ Incharge

• Nursing staff/ Incharge

• Nutritionist ( Contractual)

• Cook cum Care taker ( Contractual)

• Attendant / Cleaners ( Contractual)

• Medical Social Volunteer

CRITERIA FOR ADMISSION FOR INPATIENT TREATMENT OF CHILDREN 6-59 months

Any of the following:

• MUAC < -3 SD with or without any grade of edema

WFH < -3 SD with or without any grade of edema

• Bilateral pitting edema +/++ (children with edema +++ always need inpatient care)

WITH Any of the following complications 1. Anorexia (Loss of appetite)

2. Fever (39 degree C) or Hypothermia (< 35 C)

(37)

4. Severe dehydration based on history and clinical examination 5. Not alert, very weak, apathetic, unconscious, convulsions 6. Hypoglycemia

7. Severe Anemia (severe palmar pallor) 8. Severe pneumonia

9. Extensive superficial infection requiring IM medications 10. Any other general sign that a clinician thinks requires admission for further assessment or care.

In addition to above criteria if the caregiver is unable to take care of the child at home, the child should be admitted.

LAB INVESTIGATIONS:

• Blood glucose

• Haemoglobin or packed cell volume in children with severe palmar pallor

• Serum electrolytes eg; (sodium, potassium, and calcium whenever possible)

• Screening for infections:

™ Total and differential leukocyte count, blood culture

(38)

™ Urine routine examination

™ Urine culture

™ Chest x-ray

™ Mantoux test

™ Screening for HIV after counseling (only when suspected , based on history and clinical signs and symptoms)

™ Any other specific test required based on geographical location or clinical presentation e.g. Celiac Disease, malaria etc.

Principles of Hospital-Based Management

The principles of management of SAM are based on 3 phases:

Stabilization Phase, Transition Phase and Rehabilitative Phase.

Stabilisation Phase:

Children with SAM without an adequate appetite and/or a major medical complication are stabilized in an in-patient facility.

This phase usually lasts for 1 - 2 days.

(39)

The feeding formula used during this phase is Starter diet (F75) which promotes recovery of normal metabolic function and nutrition-electrolytic balance.

All children must be carefully monitored for signs of overfeeding or over hydration in this phase.

Transition Phase:

This phase is the subsequent part of the stabilization phase and usually lasts for 2-3 days.

The transition phase is intended to ensure that the child is clinically stable and can tolerate an increased energy and protein intake.

The child moves to the Transition Phase from Stabilization Phase when there is –

• At least the beginning of loss of edema AND

• Return of appetite AND

• No nasogastric tube, infusions, no severe medical problems AND

• Is alert and reactive The ONLY difference in management of the child in transition phase is the change in type of diet.

(40)

There is gradual transition from Starter diet (F75) to Catch up diet (F 100).The quantity of Catch up diet (F100) given is equal to the quantity of Starter diet (F75) given in stabilization Phase.

Rehabilitation Phase:

Once children with SAM have recovered their appetite and received treatment for medical complications they enter Rehabilitation Phase.

The aim is to promote rapid weight gain, stimulate emotional and physical development and prepare the child for normal feeding at home.

The child progresses from Transition Phase to Rehabilitation Phase when:

• She/he has reasonable appetite; finishes > 90% of the feed that

is given, without a significant pause

• Major reduction or loss of edema

• No other medical problem

Discharge Criteria

• for all infants and children 15 % weight gain and no sign of illness.

• This should be achieved through facility based care in NRC when community based programme is not in place.

DISCHARGE FROM NUTRITION REHABILITATION CENTRE

(41)

CHILD

• Oedema has resolved

• Child has achieved weight gain of > 15% and has satisfactory weight gain for 3 consecutive days (>5 gm/kg/day)

• Child is eating an adequate amount of nutritious food that the

mother can prepare at home

• All infections and other medical complications have been treated • Child is provided with micronutrients

• Immunization is updated. Mother/ caregiver

• Knows how to prepare appropriate foods and to feed the child

• Knows how to give prescribed medications, vitamins, folic acid and iron at home

• Knows how to make appropriate toys and play with the child

• Knows how to give home treatment for diarrhea, fever and acute respiratory infections and how to recognize the signs for which medical assistance must be sought

• Follow-up plan is discussed and understood.

(42)

Failure to Respond Criteria Approximate time after admission Failure to regain appetite Day 4

Failure to start to lose oedema Day 4

Oedema still present Day 10

Failure to gain at least 5 g/kg/day for 3 successive days after feeding freely on Catch-up diet.

Follow up of children discharged from NRC

It is important for NRC to put in place an effective tracking and reporting systems so that children do not get lost and defaulters and deaths do not go unreported.

Children discharged from NRC should be followed up at the community level to ensure appropriate feeding, follow up at the NRC for scheduled visits and to identify children who are not responding to treatment for referral to the facility level.

NRC should have a complete list of PHCs, Subcentres and Anganwadis in its catchment area, so they can refer the child to the appropriate health facility closest to their community.

Close collaboration and information sharing between NRC and community based care (at PHC, Subcenter and AWC) are essential.

(43)

The list of SAM children discharged from NRC should be shared with area specific ANM and ICDS supervisors.

These children should be enrolled in the AWC and given supplementary food as per the guidelines.

The AWWs should prioritize these children for home visits, every week in the first 4 weeks and then once in 2 weeks till the child is discharged from the program.

During the home visits, AWW should observe feeding and provide appropriate counseling and support to the mothers.

These children should be weighed every week at AWC.

The ASHA AND AWW should ensure that these children return for the scheduled follow ups at the NRC.

The ANM will also follow up the children discharged from NRC during the VHNDs till they exit from the nutrition rehabilitation program.

(44)

REVIEW OF LITERATURE

1.Das et al conducted a study of clinical profile and outcome of children with severe acute malnutrition. Among 130 patients studied 77% had Marasmus and 23% had Kwashiorkar. There was no variation in sex. Among 12.3% belonged to age group <2months,47.7% between 2months to 12 months and 40% above 12months. LBW, taking unbalanced diet, low level of maternal education, age <2 years, lack or incomplete immunization, living with single parent were predictors of malnutrition. Associated comorbidities were pneumonia, urinary tract infection and pulmonary tuberculosis. SAM children were staying longer at hospital and have a higher mortality.(4)

2. A Basait et al conducted a study on Risk factors for under-nutrition among children aged one to 5years in Udipi taluk of Karnataka,India.

LBW,interaction of short birth interval with more than 2 children in the family

(45)

and illness in the past one month were found to be significant predictors of under-nutrition. A diet without milk or a diet with diluted milk was also found to be significantly associated with under-nutrition.This indicates the need for appropriate awareness campaigns that promote birth spacing and alleviate food fads.(5)

3. Yokesh et al conducted a study on association of severe acute malnutrition with infections in under-5 children admitted to Nutritional Rehabilitation Center- study from central India.350 cases and 350 controls were chosen. Fever followed by diarrhea and ARI were most common presentations. The average time between identification of a child as severe malnourished and their admission was 4.38 months. The most important cause for delay in admission to NRC was because of work at home, care of other sibling and no information regarding NRC was given by health care worker at early stage of disease. There is strong association between SAM and infections.

SAM and infections should be treated urgently to decrease mortality and morbidity.(6)

4. Syed et al conducted a study on demographic, clinical profile of severe acute malnutrition and our experience of nutrition rehabilitation centre at children hospital Srinagar Kashmir in 2015. A total of 146 children were admitted for SAM. 54.8% were males,39.7% were in the age group of 1 to 2

(46)

years.61.65 from lower socioeconomic strata and 85% from rural Kashmir. The most common co-morbidity in SAM was AGE followed by ARI. 75.3% was recovery rate . NRCs provide life-saving care for children with SAM.

Community based therapeutic care for children with SAM needs to become a key component of the continuum of care for children with severe acute malnutrition.(7)

5. Edem et al conducted a study on Factors affecting malnutrition in children and the uptake of interventions to prevent the condition. Malnutrition was associated with poverty but not with maternal educational status and employment status. Malnutrition was also associated with lack or inadequate antenatal care, not de-worming children regularly, low birth weight, previous diarrhoea episodes, and development delay. Though the latter three conditions could be consequences of malnutrition they could aggravate malnutrition through lack of health services. Thus preventing these conditions and providing adequate follow up for diarrhoea patients will be important steps in preventing malnutrition were generally better patronized by the mothers of well nourished children. Efforts must be made to reach mothers who default on antenatal visits and de-worming their children regularly. Furthermore, growth monitoring should be encouraged in this setting and further studies on the timing and use of information from the activity are needed.(8)

(47)

6. Pravati et al Study of social and demographical of severe acute malnutrition in children aged 9-59 months in a tertiary care centre of Odisha, India. The overall prevalence of SAM in present study was 2.8% SAM was more prevalent in males as compared to females. The most vulnerable age group of SAM was found to be 6 – 12 months. Maximum patients were from rural background and belonged to lower socioeconomic status. Most common factors associated were inadequate breast feeding and weaning. This study highlighted the prevalence and basic causes associated with severe acute malnutrition are preventable, adequate measures can be taken to implement proper educational activities which promote breastfeeding, adequate, complementary feeding and also promote immunization and other health care facilities.(9)

7. Sarah at el Understanding severe acute malnutrition in children globally: A systematic Review. Severe acute malnutrition Is a devastating illness that disproportionately affects children worldwide and has become the devastating cause of millions of preventable deaths annually. In order to begin to solve this major global problem, it is Imperative that the factors that lead to the development of SAM are acknowledged and then addressed. This review demonstrates that the development of SAM is multifactorial, including socioeconomic factors, cultural factors and maternal characteristics. This study demonstrates that the most common risk factor associated with SAM is low maternal education status leading to the conclusion that this is the most important factor to be addressed in steps towards eliminating this problem.

(48)

Promoting women health and education is the most important avenue to decrease deaths from severe acute malnutrition worldwide.(10)

8. Binuet al conducted a study on Prevalence of malnutrition among underfive children in a semi urban area in Kottayam, Kerala. The present study found that 31.5%of the study population was underweight, 21.8% stunted and 14.6% wasted. Out of the total 6.4% were severely underweight, 4.9% severely stunted and 2.8% severely wasted. The prevalence of mild and severe under nutrition increases up to 12-24 months and then decreases. Thus the prevalence of severe underweight, stunning and wasting is comparatively low but the prevalence of mild underweight, stunting and wasting is unacceptably high.(11)

(49)

9. Surender et al Prevalence of Malnutrition and Associated Factors among Under-Five Children in Pastoral Communities of Afar Regional State, Northeast Ethiopia: A Community-Based Cross-Sectional Study.The present study revealed that the prevalence of wasting, stunting, and underweight were about 16.2% (95% CI: 13.8–18.8%), 43.1% (95% CI: 39.8–46.5%), and 24.8%

(95% CI: 21.9–27.8%), respectively, in the study area. This result indicated the prevalence of child malnutrition (wasting, stunting, and underweight) was a serious public health problem in the pastoral community according to the WHO classification for public health significance. According to analysis of independent variables with the outcome variables, households having a family size of five or more, receiving prelacteal feeding, and presence of diarrhoeal disease in the past two weeks were the independent predictors for increasing wasting. Being male child, increasing age child, and not fully immunized child were the independent predictors for increasing stunting.(12)

Moreover, the independent predictors positively associated with increasing underweight were being illiterate mother, being male child, prelacteal feeding practices, and not fully immunized child. Promoting use of family planning, preventing diarrhoeal diseases, and vaccinating children integrated with the access of nutrition education programs are vital interventions to improve nutritional status of the children. A due emphasis should also be given to strengthen the health extension program to improve and provide participatory nutrition education to create awareness and to develop behavior change

(50)

communication for better child feeding and caring practices in the pastoral community.

10.Deepak et al Clinical Profile of Severe Acute Malnutrition in Western Rajasthan: A Prospective Observational Study from India. On the basis of this study, we conclude that the problem of severe malnutrition is multi – dimensional and inter – generational in nature. Prevalence of severe acute malnutrition is still high in community (6.4%) as well as in hospital setting(3.28%). The determinants of severe malnutrition includes household food insecurity, illiteracy, low socioeconomic status, lack of awareness to access health services, large family size and poor purchasing power etc. besides these, faulty feeding practices, ignorance about nutritional needs of infants and young children and repeated infections, also aggravates the malnutrition amongst children. So there is strong need to educate the parents, especially mothers about nutritive diets that they can prepare at home with available means or can be purchased from market at low cost. Apart from nutritional education, importance of breast feeding time of weaning birth spacing, family planning, immunization and literacy have to be reiterated to the parents. It is very important to communicate to the policy planners the urgency to address the problem of severe acute malnutrition. The policy planners should concentrate on adequate nutrition of the girl child because the malnourished mother give rise to malnourished and small for gestational age newborn and also this leads to early weaning from breast feeding and hence this vicious

(51)

focused is the proper follow up of these malnourished children and to see the adequate growth of these children’s. the parents of these children’s need to be sensitized about the care needed. As the problem of PEM is seen mainly in low status population, hence they must be educated about the low cost and nutritious food.(13)

(52)

AIM AND OBJECTIVES OF THE STUDY:

Primary objective:

To study the “Demographic and etiological profile of severe acute malnutrition in children aged 6 months to 59 months in an urban tertiary care centre”.

Secondary objective:

1) To identify the socio demographic risk factors of SAM.

2) To study the comorbidities of severe acute malnutrition in children.

3)To study the outcome of children hospitalised with severe acute

malnutrition-in terms of morbidity and mortality.

(53)

STUDY JUSTIFICATION

Malnutrition has devastating consequences for the growth and development of the children.

It reduces a child’s immunity making them susceptible to a number of infections, for example pneumonia, tuberculosis and diarrhoea which further increases the probability of malnutrition.

Under nutrition also plays a major role in the premature deaths of millions of children in developing countries.

Those it does not kill, it renders them vulnerable to infection and disease, blighting the lives of hundreds of millions.

The mothers and fathers who stay in the wards with their admitted children are between the ages of 18 to 40 years which is the productive age group in the societies.

Early detection of patients at risk for malnutrition or at an early

stage of malnutrition, provides an opportunity to avoid the more complex

and costly interventions required ,as and when nutrition deficiencies

reach an advanced stage.

(54)

Nutrition screening, that identifies malnutrition at an early stage may reduce hospital stay to provide its own cost justification and improve outcomes.

Analysis of literature reveals that malnutrition is an independent risk factor in many disease processes and treatment of malnutrition can indeed improve the patient’s prognosis.

Such an analysis has to address several questions mainly the demographic and etiological profile of SAM in children.

The study offers knowledge on the demographic & etiological

profile of malnutrition, as well as identifying the comorbidities associated

with it & to know the outcome of SAM children.

(55)

METHODOLOGY:

Study design : Descriptive observational study

Study setting : Pediatric wards,Speciality wards, PICU of ICH&HC.

Study period : May 2018 - September 2019

Study population

Children of age 6 months to 59 months, with a clinical diagnosis of severe acute malnutrition.

Sample size

The study intends to cover the children who fulfil the inclusion criteria during the study period – convenient sample size.

Inclusion criteria

Children of age 6 months to 59 months, with a clinical diagnosis of severe acute malnutrition - either as primary or secondary association.

Exclusion criteria

Children with acute malnutrition following major surgeries.

Children with recognisable chromosomal anomalies.

Statistical analysis

Data will be entered in excel sheet. Statistical analysis of data will be

performed by statistical software SPSS version 21.

(56)

OBSERVATION AND RESULTS

A total 100 people were included in the final analysis.

Table :Descriptive analysis of age in months in study population (N=100)

Age (in months) Frequency Percentage

6 to 11 months 33 33%

12 to 23 months 30 30%

24 to 35 months 12 12%

36 to47 months 12 12%

48 to 59 months 13 13%

Total 100 100%

(57)

T

Figu

Table : Desc

G M F T

Both

ure : Bar cha

66% of chi

criptive ana

Gender Male Female Total

boys and g

0%

5%

10%

15%

20%

25%

30%

35%

Percentage

art of age in

ildren with m

alysis of gen

Fr 50 50 10

irls have sim

6 to 11 months 33%

n months in

malnutritio mon

nder in mon

requency 0

0 00

milar preva

12 to 23 months

2 30%

Age

n study popu

on were in th nths.

nths in study

Perc 50%

50%

100%

alence of ma

24 to 35 months

3 m 12%

e in months

ulation (N=

he age grou

y populatio

centage

%

%

%

alnutrition.

6 to47 months

48 mo 12%

=100)

up of 6 – 23

n

to 59 onths

13%

(58)

Table : Descriptive analysis of MUAC < 11.5 CM in study population

MUAC < 11.5 CM Frequency Percentage

Yes 41 41%

No 59 59%

Total 100 100%

41% of children had MUAC < 11.5cm.

Table : Descriptive analysis of B/L edema in study population (N=100)

B/L edema Frequency Percentage

Yes 1 1%

No 99 99%

Total 100 100%

Only 1% was admitted with features of bilateral edema.

Table : Descriptive analysis of residence in study population (N=100) Residence Frequency Percentage

Rural 45 45%

Urban 55 55%

Total 100 100%

55% of children were from urban population.

(59)

Table : Descriptive analysis of mother education in study population (N=100)

Mother education Frequency Percentage

Illiterate 12 12%

Primary 10 10%

Middle 14 14%

High 28 28%

Higher secondary 23 23%

Graduation 9 9%

Post graduation 4 4%

Total 100 100%

Malnutrition is low in children of mothers who have completed their graduation.

Table : Descriptive analysis of mother working in study population (N=100)

Mother working Frequency Percentage

Yes 15 15%

No 85 85%

Total 100 100%

(60)

T (N

85%

Table : Des N=100)

S c I I I IV

Pie cha

% of mothe

scriptive a

Socio ec class

I I II V

art of mothe

ers were hou

nalysis of

conomic Fr 16 10 64 25

85%

er working i

usewives ta

socio econ

requency 6

0 4 5

in study pop

aking care o

nomic clas

Perc 1%

10%

64%

25%

15%

pulation (N

of children a

ss in study

centage

%

%

%

N=100)

at home.

y populatio

Yes No

on

(61)

T

Fig (N=

64% o Tab (N=

B

2 3 Total

gure : Bar

=100)

of study po ble : Desc

=100)

Birth order 1

2 3

0%

10%

20%

30%

40%

50%

60%

70%

Percentage

10

r chart of

opulation be criptive an

Fr 39 47 12

I 1%

00

socio econ

elonged to c nalysis of

requency 9

7 2

II 10%

socio eco

100%

nomic clas

class 3 SEC birth orde

Perc 39%

47%

12%

III 64%

onomic class

%

ss in study

C(Lower Mi r in study

centage

%

%

%

IV 25%

y populatio

iddle Class) y populatio

%

on

) on

(62)

4 2 2%

Total 100 100%

Birth order was 2 or more in 61% of study population.

Table : Descriptive analysis of spacing&<2yr in study population (N=100)

Spacing <2yr Frequency Percentage

Yes 36 59%

No 25 41%

Total 61 100%

Table : Descriptive analysis of Antenatal anaemia in study population (N=100)

Antenatal anaemia Frequency Percentage

Yes 36 36%

No 64 64%

(63)

T

Tab

P Y N Total

Pie cha

36% of m

ble : Descri

Preterm Yes No

64%

10

art of antena

mothers had

iptive analy

Fr 13 87

00

atal anaemi

antenatal a

ysis of prete

requency 3

7

100%

iain study p

anaemia

erm in study

Perc 13%

87%

36%

%

population (N

y population

centage

%

%

N=100)

n (N=100)

Yes No

(64)

Total 100 100%

13% of study population were born pre term.

Table : Descriptive analysis of LBW in study population (N=100)

LBW Frequency Percentage

Yes 51 51%

No 49 49%

Total 100 100%

51% of study population had low birth weight.

Table : Descriptive analysis of NICU admission in study population (N=100)

NICU admission Frequency Percentage

(65)

Yes 36 36%

No 64 64%

Total 100 100%

36% of study population they were admitted in NICU.

Table : Descriptive analysis of deprivation of colostrum in study population (N=100)

Deprivation of

colustrum Frequency Percentage

Yes 34 34%

No 66 66%

Total 100 100%

66% of study population were fed with colostrum.

Table : Descriptive analysis of EBF in study population (N=100)

EBF Frequency Percentage

Yes 52 52%

(66)

No 48 48%

Total 100 100%

52% of children were exclusively breast fed.

Table : Descriptive analysis of bottle feeding in study population (N=100)

Bottle feeding Frequency Percentage

Yes 71 71%

No 29 29%

Total 100 100%

71% of children were given bottle feeds.

Table : Descriptive analysis of calorie deficit in study population (N=100)

Calorie deficit Frequency Percentage

(67)

Yes 99 99%

No 1 1%

Total 100 100%

99% of children had calorie deficit.

Table: Descriptive analysis of reasons behind calorie deficit (N=100)

Reasons for calorie deficit Percentage Wrong time of weaning 11%

Unaware of ideal weaning foods 28%

Improper dilution of milk and formula feeds

55%

Other causes 6%

Major reason behind calorie deficit is improper dilution of milk and formula feeds (55%)

Table : Descriptive analysis of immunization in study population (N=100)

Immunization Frequency Percentage

(68)

Yes 84 84%

No 16 16%

Total 100 100%

16% were either partially immunized or unimmunized.

Table : Descriptive analysis of previous admission in study population (N=100)

Previous admission Frequency Percentage

Yes 40 40%

No 60 60%

Total 100 100%

40% had history of previous hospitalization.

Table : Descriptive analysis of no of admission in study population (N=100)

(69)

No of admission Frequency Percentage

1 30 75%

2 6 15%

3 3 7.5%

5 1 2.5%

Total 40 100%

Among 40 children 25% had recurrent admissions.

Table : Descriptive analysis of mother bmiunder weight in study population (N=100)

Mother BMI under

weight Frequency Percentage

Yes 26 26%

No 74 74%

Total 100 100%

26% of mother had low BMI

Table : Descriptive analysis of temperature in study population (N=100)

(70)

Temperature Frequency Percentage

H 30 30%

L 7 7%

NT 63 63%

Total 100 100%

7% had hypothermia during admission.

Table : Descriptive analysis of pallor in study population (N=100)

Pallor Frequency Percentage

Yes 78 78%

No 22 22%

Total 100 100%

78% of children had pallor.

References

Related documents

According to Tucson children respiratory study 84 the most common respiratory infection was RSV and lower respiratory tract caused by RSV is most common risk factor for

Hence this community based study was done to find out the prevalence of malnutrition and its association with selected risk factors among children aged 0-59

Children with severe acute malnutrition have significantly reduced cardiac muscle mass, diastolic dysfunction but systolic function is relatively preserved compared

Asthma is a disease associated with various factors. These factors could be genetic or environmental or both. The environmental insult has increased the prevalence

Shah V, et al [19] did a case control study in 400 children hospitalized with severe pneumonia aged below five years at tertiary care hospital in south Kerala to identify the

Children’s minimum dietary diversity, minimum acceptable diet, minimum meal frequency Complementary feeding practices in children aged 6–23.9 months, maternal complementary

Akpede, 25 conducted a prospective study in Six-hundred- and-forty-two previously healthy children aged 1 month to 5 years with fever of acute onset, without localizing

1. Children between 2 months –59 months coming to OP with suspected pneumonia, if satisfying the inclusion criteria were enrolled into the study group and admitted or given